1932330644 NPI number — DAVID R COLEMAN OD LLC

Table of content: (NPI 1932330644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932330644 NPI number — DAVID R COLEMAN OD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID R COLEMAN OD LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COLEMAN VISION IMPROVEMENT CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932330644
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1030 SE MURPHY BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOPLIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64801-5043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-782-3488
Provider Business Mailing Address Fax Number:
417-782-8150

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1030 SE MURPHY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOPLIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64801-5043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-782-3488
Provider Business Practice Location Address Fax Number:
417-782-8150
Provider Enumeration Date:
07/29/2009

Additional Information

Authorized Official

Authorized Official Last Name:
COLEMAN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
417-782-3488

Provider Taxonomy Codes

  • Taxonomy code: 152WV0400X , with the licence number:  TO2322 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100090450B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 311427801 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com